The recent availability of safe volumizing fillers has provided cosmetic physicians with the tools necessary to contour facial features non-surgically and cost-effectively. This review focuses on outlining objective parameters necessary for creating a template to maximize each individual’s facial beauty. Phi relationships can be approached for all facial features and rely on the establishment of smooth ogee curves in all dimensions. Once goals have been determined and a budget established, a logical syntax is used to create an algorithm for selecting products and procedures. The methodology leads to consistent and pleasing results with a high rate of patient satisfaction.
Renaissance physicians: purveyors of beauty
The Renaissance Period (1350–1550) was the rebirth transition period between the Middle Ages and the modern world, and has been described as the most productive era in mankind’s history. As a cultural movement, it engulfed Europe in a revival of artistic learning based on classical sources and the development of linear perspective. Although the Renaissance saw resurgence in intellectual scientific activity, it is perhaps best known for the monumental achievements of such artistic geniuses as Leonardo Da Vinci and Michelangelo. Their influence affected and shaped the future by empowering their generation to embrace knowledge, and stood as a testament to the development of limitless skills in all the arts. These gifted Renaissance men were more than just intellectual icons: they inspired a medieval world to break free of dogmatic ideology and endeavor to develop its capabilities as fully as possible.
Da Vinci claimed, “I have offended God and mankind because my work didn’t reach the quality it should have.” It is time to rekindle his torch of commitment and excellence with a spark of passion and pride. We are the Renaissance artists of our time. Patients are our easels, their faces our canvas. We should strive to create beautiful works of art; to maximize each individual’s natural facial beauty.
The world today is immersed in an expectation economy: aesthetic consumers do not want to look just good, they expect to look fantastic; immediately, and with little downtime. Patients always budget to look great because looking great never goes out of style even in a disruptive economy. Today’s aesthetic patients realize that a youthful appearance is the best thing you can wear.
There exists a sea of sameness with a biblical flood of products, devices, and nonmedical centers, compelling aesthetic physicians to differentiate themselves through superior results. To chase lines is a guarantee of copying the competition in a race to the bottom; cosmetic specialists must separate their clinics from the monotherapist down the street by creating exceptional results through a comprehensive global approach.
The recent availability of safe volumizing fillers has provided cosmetic physicians with the tools necessary to contour facial features nonsurgically and cost-effectively. Like our Renaissance ancestors, it is incumbent on us to have a good understanding of the aesthetic goals necessary to achieve a beautiful and natural result. What should be the preferred facial volume and feature shape? What is the ideal beautiful normal for each individual face, and is there a code to unlock the patient’s potential? Is it unreasonable to have lofty aesthetic goals, or should clinicians be less principled and more moderate? Thomas Paine (1737–1809), a British author who supported the American Revolution and became one of the Founding Fathers of the United States, wrote: “A thing moderately good is not as good as it ought to be. Moderation in temper is always a virtue; but moderation in principle is always a vice.”
This review focuses on outlining objective parameters necessary for creating a template to maximize each individual’s facial beauty. The techniques offered are the unique conceptions of the authors, experienced injectors who have applied their expertise in both aesthetic dermatology and cosmetic plastic surgery. It in no way represents the sole method to nonsurgically release the patient’s facial beauty potential. The intent is to encourage aesthetic injectors to always be result oriented, to develop methodical and comprehensive approaches to facial enhancement, and to push creativity beyond rejuvenation into the realm of beauty maximization. “The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark” (Michelangelo Buonarroti).
Facial beauty
St Thomas Aquinas, known as the angelic doctor, was one of the great philosophers of the Catholic Church in the thirteenth century. He proclaimed beauty to be “integras, proportio, et claritas”: harmony, proportion, and clarity. True facial beauty arouses the senses to an emotional level of pleasure and “evokes in the perceiver a high degree of attraction” (Stephen Marquardt).
It is essential that injection specialists have a deep understanding and a well-cultivated taste for beauty. Otherwise they would be satisfied with a low and common goal rather than the maximization of beauty potential in their patients. Although certain individuals may be endowed with an innate aesthetic sense, it can be learned, at least in part, by the ardent study of art and the constant observation of facial and body proportions and relationships.
Regardless of nationality, age, or ethnic background, for the most part people universally share a sense of what is attractive. When British researchers asked women from England, China, and India to rate pictures of various Greek men, their choices were identical. When asked to select attractive faces from a diverse collection, European White, Asian, and Latino people from a dozen countries also made the same choices. Studies have shown that even babies show a sense of what is attractive: infants 3 to 6 months old gaze longer at a nice-looking face than one that is not attractive.
In a large research project on facial attractiveness at several German universities, digitally composed faces were created using a specialized software algorithm based on people’s perception of beauty. Using a 7-point Likert scale from 1 (very unattractive) to 7 (very attractive), results proved that most people, regardless of ethnicity, seem to have similar subjective ideas about what constitutes an attractive face ( Fig. 1 ). Processing attractiveness can take milliseconds; the perceiver’s eyes rapidly scan the entire face while the brain analyzes contours, shapes, features, and skin quality. Contrary to patients’ requests for line filling, affecting facial beauty goes far beyond wrinkles and furrows.
However, finding objective answers to why people regard one face as being more beautiful than another is not as easy as it seems. When viewing a beautiful face, the eye focuses on areas that are highlighted with pleasing shapes. The angles that these features create are vital to the perception of beauty; highlights located too high or too low detract from attractiveness. Review of numerous articles on facial beauty identifies 7 key facial features that seem to be subconsciously assessed when determining facial beauty ( Fig. 2 ). Four features of these Magnificent Seven (facial shape, eyebrow shape, nose, and lips) are amenable to injection contouring with fillers (eg, hyaluronic acids [HAs]) and neuromodulators (eg, botulinum toxin A [BTX-A]). The remaining 3 features (forehead height, eye size and intereye distance, and skin tone and texture) are beyond the domain of injection therapy. Skin clarity, texture, and color can be markedly improved with topical agents, present-day energy device technology, and judicial use of makeup; forehead height accentuated or camouflaged by hair style; and intereye distance disguised by creative shadowing when applying eye makeup. All this emphasizes the importance of working closely with skilled aestheticians and experienced hairdressers when offering patients global facial beautification ( Fig. 3 ).
Facial beauty
St Thomas Aquinas, known as the angelic doctor, was one of the great philosophers of the Catholic Church in the thirteenth century. He proclaimed beauty to be “integras, proportio, et claritas”: harmony, proportion, and clarity. True facial beauty arouses the senses to an emotional level of pleasure and “evokes in the perceiver a high degree of attraction” (Stephen Marquardt).
It is essential that injection specialists have a deep understanding and a well-cultivated taste for beauty. Otherwise they would be satisfied with a low and common goal rather than the maximization of beauty potential in their patients. Although certain individuals may be endowed with an innate aesthetic sense, it can be learned, at least in part, by the ardent study of art and the constant observation of facial and body proportions and relationships.
Regardless of nationality, age, or ethnic background, for the most part people universally share a sense of what is attractive. When British researchers asked women from England, China, and India to rate pictures of various Greek men, their choices were identical. When asked to select attractive faces from a diverse collection, European White, Asian, and Latino people from a dozen countries also made the same choices. Studies have shown that even babies show a sense of what is attractive: infants 3 to 6 months old gaze longer at a nice-looking face than one that is not attractive.
In a large research project on facial attractiveness at several German universities, digitally composed faces were created using a specialized software algorithm based on people’s perception of beauty. Using a 7-point Likert scale from 1 (very unattractive) to 7 (very attractive), results proved that most people, regardless of ethnicity, seem to have similar subjective ideas about what constitutes an attractive face ( Fig. 1 ). Processing attractiveness can take milliseconds; the perceiver’s eyes rapidly scan the entire face while the brain analyzes contours, shapes, features, and skin quality. Contrary to patients’ requests for line filling, affecting facial beauty goes far beyond wrinkles and furrows.
However, finding objective answers to why people regard one face as being more beautiful than another is not as easy as it seems. When viewing a beautiful face, the eye focuses on areas that are highlighted with pleasing shapes. The angles that these features create are vital to the perception of beauty; highlights located too high or too low detract from attractiveness. Review of numerous articles on facial beauty identifies 7 key facial features that seem to be subconsciously assessed when determining facial beauty ( Fig. 2 ). Four features of these Magnificent Seven (facial shape, eyebrow shape, nose, and lips) are amenable to injection contouring with fillers (eg, hyaluronic acids [HAs]) and neuromodulators (eg, botulinum toxin A [BTX-A]). The remaining 3 features (forehead height, eye size and intereye distance, and skin tone and texture) are beyond the domain of injection therapy. Skin clarity, texture, and color can be markedly improved with topical agents, present-day energy device technology, and judicial use of makeup; forehead height accentuated or camouflaged by hair style; and intereye distance disguised by creative shadowing when applying eye makeup. All this emphasizes the importance of working closely with skilled aestheticians and experienced hairdressers when offering patients global facial beautification ( Fig. 3 ).
The story of Phi
Many Renaissance scholars and artists studied ancient Greece and Rome, attempting to recapture the spirit of these cultures in their philosophies and their works of art and literature. The ancient Greeks maintained that all beauty is mathematics. Leonardo Da Vinci, in his scientific search for defining ideal beauty, stated that “no human inquiry can be called science unless it pursues its path through mathematical exposition and demonstration.”
The attractiveness of the female figure is often described in measured numbers (eg, 36-24-36), so why not the face? The idea of a mathematical code, formula, relationship, or even a number that can describe facial beauty is not a modern concept. Medieval artists were impressed by the magical number 7. For them, the perfect face was neatly divisible into horizontal sevenths: the hair the top seventh, forehead two-sevenths, nose another two-sevenths, a seventh between nose and mouth, and the final seventh from mouth to chin. Novice artists are often taught that the simplest way to approximate the relative width of facial features is to divide the face into vertical fifths with each fifth being equal to 1 eye width ( Fig. 4 ).
Only 1 mathematical relationship has been consistently and repeatedly reported to be present in beautiful things, both living ( Fig. 5 ) and man made ( Fig. 6 ): the Golden Ratio (also known as the Divine Proportion).
The Golden Ratio is a mathematical ratio of 1.618:1, and the number 1.618 is called Phi because it was regularly used by the Greek sculptor Phidias; Phi (upper case) is 1.6180339887…, whereas phi (lower case) is 0.6180339887…, the reciprocal of Phi and also Phi minus 1. This irrational number is the only one in mathematics that, when subtracted by units (1.0), yields its own reciprocal.
Used since the time of the Egyptians, the Golden Ratio was formulated as one of Euclid’s elements, one of the most beautiful and influential works of science in the history of humankind. This ratio was known to the Greeks as the Golden Section and to the Renaissance artists as the Divine Proportion. In geometry, it is a linear relation in which the smaller length is to the larger part as the larger part is to the complete line ( Fig. 7 ).
Ricketts noted that the golden calipers applied to the hand of man reveals that each of the phalanges of each finger is golden to the next in all 5 fingers (see Fig. 5 D).
Stephen Marquardt, a California-based Oral and Maxillofacial surgeon has conducted extensive research on human facial attractiveness. His pioneering work on the mathematical construction of facial form led to his controversial Golden Mask, derived from the Golden Ratio ( Fig. 8 ). Marquardt (personal communication, 2007) maintains that the evidence shows that our perception of physical beauty is hard wired into our being and based on how closely one’s features reflect phi in their proportions. His modification of Hungerford’s classic quote that “beauty is in the phi [eye] of the beholder” is convincing.
Since 2003, the authors have collaborated on a global comprehensive approach to nonsurgical facial beautification by optimizing facial volume, creating harmony, symmetry, and balance through reflation and contouring. To maintain natural results and avoid overinflation, proportions were achieved initially by the use of a golden mean caliper; a tool based on an articulated pentagon for dynamically measuring the phi ratio ( Fig. 9 ). The calipers were first used by Renaissance artists to determine the divine proportions for their compositions in stone and on canvas. Golden mean calipers initially help the aesthetic injector see Phi more as a relationship than as a number. Eventually, a geometric familiarity with the Golden Ratio develops, which leads to its intuitive expression in the injection technique.
In the absence of disease, the medial canthi remain a constant cutaneous landmark with age for each individual adult face. Measuring the intercanthal distance (x) to establish the unit length on which Phi (1.618x) and phi (0.618x) are created, aesthetic goals can now be defined to maximize each patient’s phi beauty potential.
Facial shape assessment
The single feature that matters time and again in studies on facial beauty is symmetry. Many papers have discussed attractiveness in terms of 3 tenets: symmetry, balance, and harmony. Although often referred to as the first feature of beauty, symmetry is not absolute : the left and right sides of the face should be considered more as siblings than as twins. However, the 2 sides of the lips should be regarded more as twins, with balanced upper and lower vermilion show ( Fig. 10 ).
It is crucial for the aesthetic injector to be fastidious about the use of consistent clinical photography. It not only is invaluable in planning treatment but also remains a vital aspect of the patient’s record to document aesthetic accomplishments. Facial views should include frontal (anteroposterior [AP]), three-quarter (tip of nose in line with the outer cheek), lateral, and Towne view to highlight facial contours ( Fig. 11 ). It is also beneficial for quadragenerian and older patients to provide earlier portrait photographs showing their youthful facial proportions and previously existing asymmetries.
Although dermatologic diagnoses can be made in seconds, when evaluating the aesthetic face, more time, care, and patience are warranted. Consensus guidelines point to an evolving paradigm in facial rejuvenation with a shift from the two-dimensional (2D) approach (focus on correcting dynamic facial lines) to the three-dimensional (3D) approach including loss of facial volume. In order to create great results, aesthetic physicians must have double vision: they must be able to see the third dimension in areas of volume loss as well as seeing the end result before they begin treatment. It is important to recognize that 1 size fits none and, even though each face is similar, every face is unique.
Youth and beauty are exemplified by a full and wide midface, referred to as the Triangle of Youth ( Fig. 12 ). Authoritative work on facial shape by Dr Steven Liew, an Australian plastic surgeon based in Sydney, has revealed a global standard oval facial shape that is considered attractive to people of all racial backgrounds. Liew’s Universal Angle of Beauty, the angle of inclination of the vertical ramus of the mandible, is ideally measured at 9 to 12 degrees off vertical, and can be attained by either volumizing with fillers or thinning the masseter with precise botulinum toxin injections.
Aging changes the 3D topography of the underlying facial structures, resulting in deflation and ptosis of the midface skin and soft tissues ( Table 1 , Fig. 13 ). Conventional face and brow lifting without volume replacement is unable to restore facial fullness and fails to address the issue of deteriorating facial shape secondary to soft tissue atrophy and bone resorption.
| Stage 1 | Stage 2 | Stage 3 | Stage 4 |
|---|---|---|---|
| Normal | Evidence of early soft tissue ptosis or atrophy slightly visible | Visible depression or descent | Severe depression or atrophy |
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Injectable Therapies for Localized Fat Loss: State of the Art
Noninvasive Body Contouring with Radiofrequency, Ultrasound, Cryolipolysis, and Low-Level Laser Therapy
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